Environmental barriers and time constraints

Seven studies reported on environmental issues (Angus et al 2012, Hachipola et al 2017, Hanlon and Payne 2017, Halcomb et al 2019, Kilic et al 2019, Pearson et al 2020, Sonalkar et al 2020), including the absence of a suitable examination table, structural building barriers and a lack of time, which posed significant challenges for women with mobility impairments in accessing cervical screening.

Five of these studies (Hachipola et al 2017, Hanlon and Payne 2017, Kilic et al 2019, Pearson et al 2020, Sonalkar et al 2020) reported on the lack of a suitable examination table, with participants commenting that it was painful, difficult or impossible to position comfortably. Three studies (Hachipola et al 2017, Hanlon and Payne 2017, Halcomb et al 2019) reported that participants required assistance from non-healthcare staff, such as friends or security personnel, to transfer to the examination table. In Halcomb et al’s (2019) study, involving an online survey of 178 practice nurses, respondents reported using adjustable examination tables that could be lowered to facilitate the transfer and support of patients into a comfortable position. However, one patient participant in Sonalkar et al’s (2020) study reported that although the clinic had adjustable tables they did not lower to wheelchair height, which meant the examination could not take place.

Structural building barriers, including narrow hallways and small examination rooms that hindered movement, were identified in five studies (Angus et al 2012, Hachipola et al 2017, Hanlon and Payne 2017, Kilic et al 2019, Sonalkar et al 2020). However, these five studies had small sample sizes, which could affect the generalisability of results.

Participants in Angus et al’s (2012) and Hanlon and Payne’s (2017) studies reported lack of time as a challenge, with some participants commenting that they required more time for their cervical screening appointment due to challenges with undressing and positioning on the examination table and that it was difficult to locate a clinic that could provide this. One participant in Angus et al’s (2012) study expressed the need for extra time for cervical screening as her muscles became more spastic if she was rushed. Correspondingly, Sonalkar et al (2020) reported that healthcare professionals believed they could provide a better service for women with mobility impairments if they had additional time.

Inadequate education of healthcare professionals

Inadequate training and education of healthcare professionals in performing cervical screening for women with mobility impairments was reported in five studies (Hachipola et al 2017, Hanlon and Payne 2017, Kilic et al 2019, Pearson et al 2020, Sonalkar et al 2020). Women with lower limb impairments reported that they had to educate their healthcare professional about their disabilities (Sonalkar et al 2020) and advocate for themselves in requesting cervical screening (Angus et al 2012).

In a qualitative study by Kilic et al (2019), participants (women who use wheelchairs) suggested there was a need for healthcare professionals, especially nurses, to undergo specific training in providing health screening to people with lower limb mobility impairments. Healthcare professionals also reported an absence of training and lack of experience in providing healthcare for women with disabilities (Hachipola et al 2017, Sonalkar et al 2020). Sonalkar et al (2020) found that healthcare professionals only learned how to undertake gynaecological examinations, such as cervical screening for patients with a mobility impairment, through experience and that the lack of training made them feel anxious about undertaking such procedures. These healthcare professionals also reported there were insufficient guidelines to support decision-making about pelvic examinations for women with disabilities (Sonalkar et al 2020).

This issue was also identified in a study by Hachipola et al (2017) in which healthcare professionals reported they received no training or education on how to care for someone with a disability and that this negatively affected the quality of cervical screening. Halcomb et al (2019), however, suggested that as registered nurses have completed an accredited nursing course they are deemed competent to work with people with disabilities.

Two studies (Angus et al 2012, Hanlon and Payne 2017) revealed challenges related to healthcare professionals’ attitudes to sexuality, with an assumption that women were not sexually active due to their disability.

Lack of awareness of the need for cervical screening for women with lower limb mobility impairments

Two studies reported challenges associated with lack of adequate information about cervical screening for women with mobility impairments (Hachipola et al 2017, Kilic et al 2019). Participants in Kilic et al’s (2019) study reported having inadequate knowledge about how cervical screening could be undertaken for a wheelchair user, which deterred them from attending screening.

Peterson et al (2012) undertook a randomised controlled trial to examine the effects of an intervention involving an educational workshop and telephone support system on uptake of cervical screening for women with mobility impairments. The researchers found that the intervention group received more cervical screenings than the control group at post-test, which suggested that education and telephone support could improve screening uptake among this population. There was 26% attrition over the course of the study, with a high proportion of attrition in the intervention group, which has a potential for selection bias.

Modifications for cervical screening procedure

Four studies discussed using a modified technique to undertake cervical screening, including alternative positioning and use of pillows (Angus et al 2012, Halcomb et al 2019), lying on the floor instead of the examination bed (Halcomb et al 2019) and undertaking the screening while standing up, when this was an option (Hanlon and Payne 2017).

The practice nurse participants in Halcomb et al’s (2019) study reported altering the technique for speculum insertion to accommodate women with reduced hip movement and supporting the patient with dressing and transferring on and off the examination table. These participants also reported that modified access such as ramps and accessible consultation rooms were available in clinics (Halcomb et al 2019). Only 60% of participants in this study had experience of working with people with physical disabilities (Halcomb et al 2019). Participants in Angus et al’s (2012) study discussed accessible health centres that offered longer appointments, accessible rooms and equipment and support staff, however one participant expressed that she did not want to be segregated.

Two studies (Halcomb et al 2019, Sonalkar et al 2020) discussed the use of medicine as a modification, such as the administration of analgesia or mild sedatives, which were reported to be helpful during pelvic examinations such as cervical screenings. One participant in Pearson et al’s (2020) study reported she could not have cervical screening without analgesia but that her GP or primary physician was unwilling to administer this and had referred her to hospital for examination under sedation.

Previous relationship with the healthcare professional

Patient participants in two studies identified that having a relationship history with the healthcare professional improved the cervical screening process (Hanlon and Payne 2017, Sonalkar et al 2020), while healthcare professional participants in Sonalkar et al’s (2020) study noted that when they were aware of patients’ needs in advance they could provide more efficient cervical screening. Participants in the study by Hanlon and Payne (2017) suggested that having a trusting relationship with their healthcare professional encouraged them to attend cervical screening appointments and this relationship facilitated a tailored approach to the procedure.

Challenges

One of the main challenges identified in the studies reviewed related to accessing the examination room and, specifically, the absence of a suitable or adjustable examination table. This challenge is reflected in a US-based online survey of wheelchair users (n=432) that explored respondents’ experience of accessing healthcare (Stillman et al 2017). Most respondents reported that the main barrier was the examination room and the availability of an adjustable examination table; several respondents indicated that they did not attend cervical screening due to the challenges of transferring to and from the examination table (Stillman et al 2017). These findings suggest that those involved in undertaking cervical screening lack awareness of how to support individuals with lower limb mobility impairment to transfer to an examination table.

A UK study of women’s (n=34) experiences of cervical screening reported that they found the process embarrassing, uncomfortable and painful (Armstrong et al 2012). Women with mobility impairments have reported the added embarrassment of requiring assistance from friends (Kilic et al 2019) or from a security guard (Hanlon and Payne 2017) to transfer to the examination table. Halcomb et al (2019) discussed how one woman with a physical disability was supported to have cervical screening while lying on the floor, as she was unable to transfer to the examination table. While the researchers did not provide information on the woman’s opinion of this situation, it could be argued that this was an undignified approach to healthcare delivery.

Nurses responsible for cervical screening must review their environment and resources to ensure they can adequately support people with lower limb mobility impairments. While some GP and/or primary care services are equipped to support people with lower limb mobility impairments, this is not available in all areas (Groenewegen et al 2021). To address environmental barriers, other screening methodologies should be explored. For example, there is evidence to suggest the validity of HPV self-sampling in ‘hard-to-reach’ women (Madzima et al 2017), although there has been little research completed on its use among individuals with mobility impairments to determine if this is a viable option.

Inadequate education and training for nurses was also identified as a challenge to accessing cervical screening and there was a suggestion that nurses often felt ill-equipped to manage the needs of women with mobility impairments. Although Halcomb et al (2019) implied that all registered nurses are deemed competent in providing healthcare services to people with disabilities, this was not reflected in the studies reviewed. The authors of this article examined a qualitative study of the experience of women with cerebral palsy in relation to screening programmes such as cervical screening (Shah et al 2022). Although this study related to the aim of the literature review, it was published outside of the search strategy date range and was not therefore included. Nevertheless, the message from the study was the effect of the presence or absence of education in relation to the woman’s disability on their participation in cervical screening. Participants expressed that nurses did not understand their disability and how it might affect cervical screening, and believed there was a need for better education and training for all nurses (Shah et al 2022).

Specific education and training should be provided to nurses undertaking cervical screenings and should include supporting individuals with lower limb mobility impairments to ensure safe practice and equity of care. Additionally, practice should be supported with relevant guidelines – which Sonalkar et al (2020) suggested were absent in many clinical areas – to assist decision-making. An example of the type of decisions healthcare professionals encounter in this context is balancing the risk to women of undertaking cervical screening under sedation with the benefits of having cervical screening (Sonalkar et al 2020). Jo’s Cervical Cancer Trust (2019) has also recommended that GP practices should review their policies on cervical screening to ensure pathways and resources are available to facilitate access for all women with disabilities.

The misconception that women with mobility impairments do not require cervical screening as they are not sexually active was referred to in two studies (Angus et al 2012, Hanlon and Payne 2017). This misconception was also identified by Shah et al (2022) – with one participant discussing how she felt her sexual health was not taken seriously by her doctor with an assumption that she was not sexually active – and cited in a report by Jo’s Cervical Cancer Trust (2019), where 20% of women reported that assumptions were made that they were not sexually active due to their physical disability. Given the higher incidence of cervical cancer in women with mobility impairments (Iezzoni et al 2021), nurses should raise awareness of this fact and ensure their colleagues are aware of the need for cervical screening in this population.

The review also identified a lack of information on cervical screening for women with mobility impairments (Hachipola et al 2017, Kilic et al 2019), which may contribute to lower rates of uptake. One study reported an increased uptake of cervical screening in women with mobility impairments following education workshops and telephone support (Peterson et al 2012), which emphasises the important role of education in enhancing attendance. Nurses have an important health education role in advising and promoting the uptake of cervical screening (King and Busolo 2022).

Potential solutions

Strategies to improve access to cervical screenings identified in the review included modifications, such as the use of alternative techniques for undertaking the procedure (Angus et al 2012, Hanlon and Payne 2017, Halcomb et al 2019, Sonalkar et al 2020).

Having a therapeutic relationship with the healthcare professional was also found to improve access (Hanlon and Payne 2017, Sonalkar et al 2020); this relationship supported a more person-centred approach because the nurse was more aware of the woman’s needs (Hanlon and Payne 2017). This important strategy supports a primary care-based approach to cervical screening where relationships with healthcare professionals such as nurses are already established, rather than delivery of the procedure in hospital settings.

Strengths and limitations

A strength of this review is the insight gained from studies that examined healthcare professionals’ and women’s perspectives, thus providing a more comprehensive understanding of the challenges involved in access to cervical screening for women with mobility impairments. The review also provides a unique focus on nursing practice in relation to cervical screening for an under-screened population. In addition, a double-screening approach was adopted for the search strategy to enhance rigour.

In each study, definitions of and the terminology used to describe physical disability varied. This created challenges in making comparisons across the studies and made summarising the findings complex. However, all the studies reviewed had commonalities in some form of physical impairment that affected the woman’s ability to move.

The term ‘adult women’ was used in the inclusion criteria in the literature search as this was the focus of the review, however the authors recognise this may not be fully representative of all individuals with lower limb mobility impairments who require cervical cancer screening. The authors suggest there is some transferability value of the findings to other populations with lower limb mobility impairments who require cervical screening.

Finally, while the review focused on cervical cancer screening, four studies also contained data on other types of cancer screening that could have negatively affected the quality of reporting in relation to cervical screening.